GW1-2023-02073_Well Construction - GW1_20230307

WELL.CONs,rRUcr[ON RECORD For lazmalUsc.DNLY:
This farm can be mcd fur single or maltipk netts
1.NVr Kiintractor Information:
-I.LAV1TER'LONCS .
Brian Ewing FROM TO I 0051'RIPTION
Well Coroaclor N,'Ime
It. fG j
4240-B
NC Well Co=crorCcnificatimNan:hcr IS:'OtITER CASi11G'(fu`r'iuulli ciivell iictlsl OR I iNER'f[f.3' [lcahk
rnON1 TO DF.A6rF.TEH TFi1CF cESS NIATEntA1.
SAEDACCO Inc 0 (L 6 fL- 1" In 8CH-40 PVC
I&INNER.CASING OR TUHING{'tciihefniul'cWscJ hxt t
FROM I TO DIMMETER I TWILNES5 I MATEfifAL
2.lYc1t Con. jVCtfon Fct'cuit n: 70003216 R. ft. hi
List jilt r,Fphrahk ur?lpenW.s(hr.Co7rnn+.:510,t,U jdarcr.Irj2C�Cll rtr.l R� fl, iR
3.wclt.tisp(chock wdl use': 171 SCRUN
Water Supply Widlr FROM Tim 1 WANrr;Tt,H I S10rS17Y I T1IICKNrtis I MATnritm,
riAgrfcultumi ON'Junicipalftb)ic 6 ft, 16 ff. 1" i2 .010 SCH-40 PVC
®Geothcmiat(Head Cooio ) ®Residential Walcr Su fL R: la
lt� l 'Sri I'3 hIP 5 pply(single)
OludustriaUContntercial ®Rcsidendal Witer•Supply(shared) �ISXROUT_ --
FROM iO. NATERUL EMPLACENIENT AtETt1OD 4 A,NIOUNT
01rri ►tion it. fl,
11Tpn WaterSuppty NVOR:
MManitoritr>; QRccati'cr? R, tt
fripction Well:
ClAgttifcr Rcctiargl! Wiroundt}Tiler R.Gitctl tion =191SANDIGRAVELPAGK'lif u t`tlirgbte)^'
FROM 70 NLt'rF,HrAI, Fs1Pt,,1C.t.\1f:Y7'SfE1'llgU
❑Aiinifcr.SwWc and Recovery ❑$alfnitY 8arricr 4 R. 16 h, FILTER SAND # 2
❑Arillifer Test.
ri.. rL
❑E,.Tcristicntal TcOinotog'. 0SiLbsicicace.Cordto
111.DRIL LING,LOG'tnitach'addltiuoid sh&t if itcecssi(r•v}
❑Geollteryil(ClosedLoop) OTrai:er F*RONt I TO 1113,547,RIPTION(obr.hnnrnen,vit4r+ichR .^ 'nwr,sit.l
❑Geothermal(Floating+Cooling Return) ❑Olher(explain under.421 Retnads) 0 ft. 5 ft, FILL :SILT AND SAND
5 ft. 15 fL MOIST TO WET SILT/ CLAY
4:Date lVetl(s).Coolpleled: 2-10-23 `Welt lWTMW-9 15 (L 16 fL WET SILTY SAND
5a.wal Lacatinn: ft. rL
^,
Space Craft ft. FL
Facility,IDwncrNmw Facility ilUl6ifappliabic) R. ft. r
525 Parkwood Ave.., Charlotte, NC, 28206 ft. fL
MAR 9
Ph}steal Addr-ss.City.and Zip 21.REMARKS -
BENTONITE SEAL 1 TO 4'
Mecklenburg ,,�...•�'•'
Cnetul} Pored hlenlificdlonNo.(PIN)
56.I.ittitude and 1,011gitadc in dch Vf;51miriutcslscgonds at,decimal dcgr ecs: 22:Certiticatlon:
(it p ell&W.Orr latflgng ig xrdlicierul
i, lY 2/14/2023��
Sigwturzz 6mitiffcilWell Coitractor Da1c r
6.ie(aYC)lhe'NYeli(s)t L7Pl'ItUat►Cttt or zTerporary ifr signbty thin fanrrJ hereby'cerrifv thorn ML❑•ellfs)t..w j%rreJ ew.rrrue•red irr.rrcxonhance
iikh 15+t r1'CW 0247,01M or I m NCAC ak;1?100}}i'11 f p_B'.417i1C71Nr SkirYltTf115<Hlrl J1LiJ[T
7.Ls this a nliair to an fisting w•ellr 0Ws fir Milo vrrofthly rennyl W 1rorn i;mride4l ruahn mr/i owner,
if rhfs:J,o r FtrJr,fill rnvr krniar ri'ril c orurnirrltui hrjorrn zrton tizrrl t t(raln ,mrnre of the
repair a,rder 02l'iernarks.recdan or wi the brisk of duty forna 23:Site diagram or additional well defails:
You may use tlfe,back of this urge to piovideadditional well site detaits;or bell
8.rumberof wells constructed: 1 consuuction delIaits. You May ilLo attachaslditionat.Pages if necessan-.
For tirnldple irrjesdon or orni-miner rnpWy w eqs ONLY high did same corrsrrjiYrtau,yva edto
r.kntirvne%rr�. SUBMiTTAL iNSTUC.TiONS
0.TOW well depth below land surfam 16 (ft.) 244L For All Wtzlls Sribntit this'fami within 31, days of compled6u of Ivell
Fornrailripfc��rilslisrniltfrprhsifJJ(tirrnJ(rxnnplc-�@2M'<wd.2@AW) constmctionto(Iwfoilotsiug:
10.Stntic}eater level below top of easingi (f.) Divisiun ut'Water Resources,lnfurmatiun Processing Unit,,
if u'axa&I'd Js irboru['tlbi/t'z lire"+" 1611&1ailservice.Center,Raleigh,YC 27609-1617
I.Borehole diamcter.2.25" (im) mob,rtar 1111gaion%ih ONLY: •in addition to sending the fomi to the address in
21'aabo�e.also submit a copy of this faith within 30 days-of completion of%Ut
12.NMI consttvtctfou method,DRIVEN Construction to the(blloml'ille:
(i.e.auger.return}',cable,direct push etc:l Division of Water Risouree's,Uudcrground[nJection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 MA Service Center.Raleigh,NC 27699-1636
1344 Yield(�in1) Nlcthod of test: 24c.For Water Suuenly.tin trajection Wet15:
Also submit orw copy of this f6f6i %0ilhin 30 days ofcompletion.of
13h.Uisinfcetion type., Amount: well commiction to the county health department of the county where
cowructcd.
Fenn G%V-1 North Corollna Dkpannucra.of Enriwnaxia aid Nmnral Resources-Division of Waler ReaLran Revised August 13
I